Female Sexual Problems - Female Sexual Dysfunction Vaginismus

Sexual Health and
Sexual Problems

Sexual health refers to the ability to enjoy sex. It also includes
birth control,
abortion, and the avoidance and treatment of
sexually transmitted disease.

Sexuality is an important part of health, quality of life, and general wellbeing. As a consequence of the impact of
Viagra on male sexual dysfunction, considerable attention is now being paid to sexual dysfunctions in women, which might respond to pharmacological treatment.

In 1918, Marie Stopes published some letters
from women who expressed their anxieties about
their ?unnatural? sexual desire or lack of pleasure
in sexual intercourse. Stopes stated that
enjoyment of sex could be brought about through
information, education and good
contraception.

Sexual dysfunction is more prevalent for women (43%) than men (31%). Women of different racial groups demonstrate different patterns of sexual dysfunction. Differences among men are not as marked but generally consistent with women. Experience of sexual dysfunction is more likely among women and men with poor physical and emotional health. Moreover, sexual dysfunction is highly associated with negative experiences in sexual relationships and overall well-being. Sexual dysfunction is an important public health concern, and emotional problems likely contribute to the experience of these problems.

Female sexual arousal is strongly modulated by thoughts and
emotions triggered by the state of sexual excitement. An
emotional relationship with the partner and emotional wellbeing
are the strongest predictors of absence of sexual distress.

Spontaneous sexual desire is common among
younger women and those in new relationships. It
can be cyclical in younger women and can be
disrupted by medical intervention. However, in
some women innate desire can endure for decades.

A Model Of Female Sexual Response
- After Taylor and Francis

Stage One - Excitement

This stage
can last anywhere from a few minutes to several hours. Sexual
activity during this stage is often called foreplay. Extending
foreplay can sometimes make the other stages more intense.
During this stage:

the blood flow to the genitalia increases

the clitoris swells

the vagina begins to lubricate (becomes wet and slippery)

blood flow to a woman's breasts increases and her
nipples may get hard

heart rate and blood pressure increase

breathing may speed up

Stage Two - Plateau

During this
stage:

due to increased blood flow, the outer third of the
vagina swells and the genitalia appear darker

the clitoris is very sensitive and retracts beneath its
hood

heart rate, blood pressure and breathing continue to
increase

muscle tension increases and spasms may occur in the
feet, face and hands

Stage Three - Orgasm

This stage is
also called climax. During this stage:

muscles in the outer third of the vagina contract in a
rapid series of pulses

the first
contractions are the most intense and the closest
together

the muscles in the uterus also contract

heart rate, blood pressure and breathing are at their
highest rate

the skin may appear red or flushed (this may begin in
earlier stages)

Orgasm is the
shortest of the four stages, usually measured in seconds.

Just before
or during orgasm, some women release a clear fluid from their
urethra. This is now commonly called female ejaculation. Most
researchers believe that this is not urine, but
instead a clear fluid similar to the fluid containing a man's
sperm. Ejaculation is most likely to occur when a woman is being
penetrated vaginally and pressure is being applied to the top
wall of the vagina. This is where the back of the clitoris meets
the wall of the vagina and is sometimes called the G-spot.

Stage Four - Resolution

During this
stage:

a woman's clitoris and nipples become softer

the vagina and genitalia return to their normal size and
colour

breathing, heart rate and blood pressure decreases

This process
typically takes longer for women than men, although some women
may be able to return to the plateau stage at this point.

Low sexual desire is more likely to occur in women in
relationships for 20-29 years (odds ratio 3.7) and less likely
in women reporting greater satisfaction with their partner as a
lover or who placed greater importance on sex. Low genital
arousal is more likely among women who are perimenopausal (4.4), postmenopausal (5.3,), or depressed (2.5), and is less likely in women taking hormone therapy (0.2), more educated (0.5), in their 30s (0.2) or 40s (0.2), or placed greater importance on sex (0.2). Low orgasmic function is less likely in women who are in their 30s (0.3) or who placed greater importance on sex (0.3). Sexual distress is positively associated with depression (3.1) and is inversely associated with better communication of sexual needs (0.2). Relationship factors are more important to low desire than age or menopause, whereas physiological and psychological factors are more important to low genital arousal and low orgasmic function than relationship factors. Sexual distress is associated with both psychological and relationship factors.

Studies indicate that less than half of patients' sexual concerns are known by their physicians, and physicians are unaware of how common these sexual concerns are in their practices. Nussbaum et al mailed their survey in waves. Of 1480 women seeking routine gynecological care 964 responded. The main outcome measures were self-reported sexual concerns and their experiences with discussing these concerns with a physician. A total of 98.8% of the women we surveyed reported one or more sexual concerns. The most frequently reported concerns were

lack of interest (87.2%)

difficulty with orgasm (83.3%)

inadequate lubrication (74.7%)

dyspareunia (71.7%)

body image concerns (68.5%)

unmet sexual needs (67.2%)

need for information about sexual issues
(63.4%)

More than half reported concerns about physical or sexual abuse, and more than 40% reported sexual coercion at some point in their lives. It was concluded that sexual health inquiry should be a regular and important part of health care maintenance.

DSM-IV classification of female sexual dysfunction: 1999

Sexual Desire Disorders

Hypoactive sexual desire disorder

Sexual aversion disorder

Sexual Arousal Disorder

Orgasmic Disorder

Sexual Pain Disorders

Dyspareunia

Vaginismus

Other sexual pain disorders

Basson et al evaluated and revised existing definitions and classifications of female sexual dysfunction. An interdisciplinary consensus conference panel consisting of 19 experts in female sexual dysfunction selected from 5 countries was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease. Classifications were expanded to include

psychogenic and organic causes of desire

arousal, orgasm and sexual pain disorders.

An essential element of the new diagnostic system is the "personal distress" criterion. In particular, new definitions of sexual arousal and hypoactive sexual desire disorders were developed, and a new category of noncoital sexual pain disorder was added. In addition, a new subtyping system for clinical diagnosis was devised. Guidelines for clinical end points and outcomes were proposed, and important research goals and priorities were identified.

Sexual problems can be primary or secondary and
generalised or situational.

Physical illness and
medication should be considered, but psychological
factors are often more important. In some cases
there is more than one dysfunction; for example, the
woman who experiences sex as painful can develop
vaginismus and then have problems becoming
aroused. Avoidance of sex can follow and this can
lead to loss of intimacy and relationship problems.

Desire disorders become more common as women
age. Desire is affected to some extent by hormones;
loss of desire can be experienced at the menopause,
regardless of age, and is often reported after a
surgically-induced menopause. From early to late menopausal transition, the percentage of women with scores indicating sexual dysfunction rose from 42% to 88%. Decreasing scores correlated with decreasing oestradiol but not with androgens. By the postmenopausal phase there was a significant decline in sexual arousal and interest, Frequency of sexual activities, and the Total Score. There was a significant increase in vaginal dryness and dyspareunia and women's reports of their partner's problems in sexual performance. Women with low scores of sexual functioning were more likely to be distressed on the Female Sexual Distress Scale. There is a dramatic decline in female sexual functioning with the natural menopausal transition.

If a
woman expects sexual activity to be rewarding she
may well embark on it and enjoy it, whatever her
hormonal status. There can be negative
psychological factors such as distraction, prediction
of a negative outcome because of previous
experience of pain, guilt, low sexual esteem, shame,
embarrassment and awkwardness. These factors
can be the result of earlier negative experiences
triggered by culture, loss, trauma or past relationships. Women may learn to keep a tight rein
on their emotions generally to avoid conflict and, in
particular, to suppress anger.

There may be
problems in the current relationship or with a
partner?s sexual dysfunction or there may be
inadequate stimulation. Depression is a common
cause of loss of desire and selective serotoninreuptake
inhibitors (SSRIs) affect the sexual response and orgasm in men and women. The existing literature confirms sexual dysfunction as a possible adverse event of all antidepressants, but it is not sufficiently robust to support claims for differences in the incidence of drug-induced sexual dysfunctions between existing antidepressant therapies.

It may help women with hypoactive desire disorder to know that many women do not have spontaneous sexual desire. Thus, treatment can be centred away from why a woman does not have such thoughts and focused on how she can access sexual satisfaction.

Certain types of oestrogen (HRT) therapy are associated with increased Frequency of sexual activity, enjoyment, desire, arousal, fantasies, satisfaction, vaginal lubrication, and feeling physically attractive, and reduced dyspareunia, vaginal dryness, and sexual problems. Certain types of testosterone therapy (combined with oestrogen) are associated with higher Frequency of sexual activity, satisfaction with that Frequency of sexual activity, interest, enjoyment, desire, thoughts and fantasies, arousal, responsiveness, and pleasure. Whether specific serum hormone levels are related to sexual functioning and how these group effects apply to individual women are unclear. Other unknowns include long-term safety, optimal types, doses and routes of therapy, which women will be more likely to benefit from (or be put at risk), and the precise interplay between the two sex hormones.

In surgically menopausal women (both ovaries have been removed, usually during hysterectomy) with hypoactive sexual desire disorder, a 300 mug/d testosterone patch significantly increases satisfying sexual activity and sexual desire, while decreasing personal distress, and is well tolerated through up to 24 weeks of use. Tibolone is licensed for the treatment of loss of desire among postmenopausal women.

A woman with sexual arousal disorder cannot
access excitement when she wishes to be sexual.
Studies show that she may experience the swelling
and lubrication of physical arousal but have little
subjective experience of pleasure. In women, peripheral feedback from consciously detected genital arousal seems to be a relatively unimportant determinant of subjective sexual arousal.

A woman may prevent
herself from accessing pleasure for a variety of
reasons or she may be mentally disengaged and
unaware of any sensations of arousal. There is a
small group of women who report subjective
feelings of arousal but who do not become
physically aroused. Peripheral neuropathy
secondary to diabetes, spinal cord injury and
surgery may be implicated.

Pharmacological and
physical treatments include the use of estrogen,
lubricants and vibrators. There may be a place for
drugs that increase vasocongestion and vasodilation. One study examined the effect of a single oral dose of sildenafil citrate (, Pfizer, Inc., New York, NY) on vaginal vasocongestion and subjective sexual arousal in healthy premenopausal women. Twelve women without sexual dysfunction were randomly assigned to receive either a single oral 50 mg dose of sildenafil or matching placebo in a first session and the alternate medication in a second session. Subjective measures of sexual arousal were assessed after participants had been exposed to erotic stimulus conditions. Vaginal vasocongestion was recorded continuously during baseline, neutral, and erotic stimulus conditions. At the end of each session, subjects were also asked to specify which treatment they suspected they had received. Significant increases in vaginal vasocongestion were found with sildenafil treatment compared with placebo. There were no differences between treatments on subjective sexual arousal experience. Analyses by suspected treatment received found that significantly stronger sexual arousal and vaginal wetness were reported for the treatment that was believed to be sildenafil vs. the treatment that was believed to be placebo. The suspected treatment se quence was incorrect for half of the women. Sildenafil was well tolerated, with no evidence of significant adverse events. Sildenafil was found to be effective in enhancing vaginal engorgement during erotic stimulus conditions in healthy women without sexual dysfunction but was not associated with an effect on subjective sexual arousal.

However, the evidence does not
show sildenafil to be an effective treatment for women with sexual dysfunction. In a review the pathophysiology of female sexual dysfunction (FSD) and the literature regarding the use of sildenafil in its treatment, search terms included female sexual dysfunction; sexual dysfunction, psychological; phosphodiesterase inhibitors; and sildenafil. The lack of a clear understanding of FSD contributes to the limited treatment options available. Studies regarding the safety and efficacy of the phosphodiesterase 5 inhibitor sildenafil in the management of FSD were evaluated. Many trials have been of poor quality, making clinical application of their results difficult. The current literature does not show sildenafil to be an effective treatment option for FSD.

Persistent sexual arousal is an uncommon condition that was first reported in 2000. The disorder is
characterised by sensations of spontaneous and
persistent genital arousal that occur without any
conscious awareness of sexual desire; orgasm offers
only temporary relief. Women are very distressed by
this condition, the causes of which are as yet
unknown; no definitive treatment can be
recommended.

An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia (muscle relaxation) that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment.

Anorgasmia (inability to experience orgasm) is more common among younger
women, demonstrating that sexual response is a
learned response. The problem of anorgasmia may
be constant, or may occur only with a partner or with
penetration.

Women's orgasms can be induced by erotic stimulation of a variety of genital and nongenital sites. As of yet, no definitive explanations for what triggers orgasm have emerged. Studies of brain imaging indicate increased activation at orgasm, compared to pre-orgasm, in the paraventricular nucleus of the hypothalamus, periaqueductal gray of the midbrain, hippocampus, and the cerebellum. Psychosocial factors commonly discussed in relation to female orgasmic ability include age, education, social class, religion, personality, and relationship issues. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Cognitive-behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. To date there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women.

Sex education,
communication skills training and Kegel exercises are often included in cognitive behavioural treatment programmes for anorgasmia. To date there are no trials showing that any
pharmacological agent is more efficacious than
placebo in enhancing orgasmic function among
these women.

Menopause and sexuality: key issues in premature menopause and beyond.

It is modulated throughout life by life and
reproduction-related events, health, relationships, and sociocultural
variables.

The aging process and menopause are two potent
contributors to female sexual dysfunction.

The earlier the menopause, the more severe and complex the
impact on sexuality is.

The younger the woman, the less she realizes the different
key goals of her life cycle (falling in love, having a satisfying sexual
life, forming a stable couple, getting married, having a family) and the
more pervasive the consequences on her sexual identity, sexual function, and
sexual relationship can be.

Premature menopause is an amplified paradigm of the
complex impact menopause can have on women's and couple's sexuality.

Dyspareunia

Almost every disease to which the sexual organs are
liable can cause dyspareunia; they can be classified
by anatomical location.

Chronic vulval pain

If there is chronic vulval pain, dermatological
conditions, such as the dermatoses, lichen sclerosis
and psoriasis, should be excluded by genital
examination.

Vulvar vestibulitis is characterised by
pain at the vaginal introitus on attempted
penetration, tenderness in the vestibule and
erythema. This is a common presentation among
young women that is poorly recognised by primary
care doctors and some gynaecologists and
frequently misdiagnosed as recurrent thrush.

Women may repeatedly seek a correct diagnosis from a variety of clinicians over a long period. Recent work has
demonstrated that women with vestibulitis have
lower pain thresholds in the vestibule and lower
tactile pain thresholds compared with controls.
Some authors suggestthat vestibulitis represents
one end of a continuum of common vulval signs
and symptoms.
Relevant studies reporting more depressive symptoms and somatic complaints have found no link between vestibulitis and sexual or physical abuse.

Pelvic pain

Pelvic pain is a common complaint and many
women present because they want an explanation.
Consultations that elicit the woman?s own ideas
about the origin of the pain will result in a better
doctor?patient relationship and improved cooperation
with investigation and treatment. In one study a history of physical or sexual abuse in
childhood was significantly more common
among women with chronic pelvic pain than
among those with chronic pain in other locations
or among controls. The history of physical and sexual abuse in childhood and adulthood was assessed in 31 women with chronic pelvic pain, 142 women with chronic pain in other locations, and 32 controls. Thirty-nine percent of patients with chronic pelvic pain had been physically abused in childhood. This percentage was significantly greater than that observed in other chronic-pain patients (18.4%) or controls (9.4%), though the prevalence of childhood sexual abuse did not differ among the groups (19.4, 16.3, and 12.5%, respectively). Abuse in adulthood was less common and was not significantly more likely to have occurred in patients with chronic pelvic pain than in other chronic-pain patients or controls.

Management requires an understanding of
psychosexual function and an ability to communicate
about sexual matters. The clinician should be alert to
non-verbal communications that indicate anxiety.
For example, a relationship problem or a history of
abuse may be suspected, but the woman may not want
to talk about it and will experience direct questioning
as intrusive.

The management of some sexual problems may
require more time and expertise than are available
in a general clinic. However, listening to the woman
in an active way and understanding the exact
nature of the problem and its impact on her and
her relationship, if she has one, can in themselves be
therapeutic.

Some women need permission to enjoy their body
and relaxation techniques can be of benefit.
Specific self-examination or the use of vaginal
trainers may be indicated for vaginismus.
Education can be helpful, but there is a wealth of
readily available information in women?s
magazines and on the internet; it might be
interesting to explore why a woman has not been
able to access it herself.

Pain syndromes may
respond to local anaesthetic creams, tricyclic
antidepressants or other interventions such as
biofeedback or cognitive behavioural therapy.
Relationship issues that are identified may be the
cause of or secondary to the problem.

The importance of sexual
difficulties in gynaecology
and obstetrics

Gynaecological conditions and procedures can
distress women and cause sexual problems.
Sexual pleasure improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. Regardless of the surgical technique
used, some women miss the uterine contractions
associated with orgasm; removal of the cervix can
change the experience of deep penetrative
intercourse. Patients who are disease free after RT for locally advanced, recurrent, or persistent cervical cancer are at high risk of experiencing persistent sexual and vaginal problems compromising their sexual activity and satisfaction.

In obstetrics, a re quest for a caesarean section without an obstetric problem might
indicate an underlying sexual problem. Sexual
difficulties can appear after birth trauma.
There is a significant decrease in sexual satisfaction scores in women who undergo vaginal delivery in comparison with those who have elective caesarean section at 2 years follow-up.

Some women present with a direct appeal for help
with a sexual difficulty.Women expect their doctors
to be able to discuss sexual problems, but some
doctors feel uncomfortable talking about sex and
may not see it as part of their clinical role.
Routinely asking about sexual function lets the
woman know that sexuality is an important aspect
of health.

Covert presentation of a sexual difficulty can take the
form of

complaints about pelvic pain

distress about
menses

general dissatisfaction with a contraceptive
precaution

expression of distaste for the genital area
or dissociation at the time of genital examination.

A
sympathetic doctor will be alert to these clues and will
ask open-ended questions to explore these issues.
New thoughts on
the classification of
sexual problems.

Should women's sexual problems be conceptualized in the same
way as men's? A telephone survey of women used Computer Assisted
Telephone Interviewing and Telephone-Audio-Computer-Assisted
Self-Interviewing methodology to investigate respondents' sexual
experiences in the previous month. A national probability sample
was used of 987 White or Black/African American women aged 20-65
years, with English as first language, living for at least 6
months in a heterosexual relationship. The participation rate
was 53.1%. Weighting was applied to increase the
representativeness of the sample. A total of 24.4% of women
reported marked distress about their sexual relationship and/or
their own sexuality. Physical aspects of sexual response in
women, including arousal, vaginal lubrication, and orgasm, were
poor predictors. In general, the predictors of distress about
sex did not fit well with the DSM-IV criteria for the diagnosis
of sexual dysfunction in women.

The new definitions recognise the importance of the
context of the sexual relationship and the fact that
sexual response phases overlap. There is an
acknowledgement of the importance of responsive
desire triggered by physical and mental arousal
rather than spontaneous desire.
Seventy percent of women in long-term
relationships report no spontaneous sexual desire
but they are able to access sexual and emotional
pleasure from sexual activity (responsive desire).
This starts from a willingness to be sexual and, with
the appropriate stimulation in context, they are able
to access arousal, leading to sexual pleasure and a
willingness to be sexual on the next occasion. The
willingness to be sexual derives from a wish for
intimacy, to stabilise her own and her partner?s
mood and to satisfy her own sexual needs as well as a
wish for non-sexual gains.

Medical Training For Sexual Dysfunction Management

A postal questionnaire was sent to the 218 GPs on the Camden
and Islington Health Authority List. A total of 133 GPs
responded to the questionnaire. Although only eight had a
special interest in sexual health, 41 and 50 reported a special
interest in mental and women's health, respectively. Forty-six
had received postgraduate training in taking a sexual history,
45 in the diagnosis of a sexual problem, 49 in the management of
sexual dysfunction, 39 in psychosexual counselling and 24 had
training in all four areas. Most GPs (87) categorized sexual
dysfunction as medium priority, 25 as high priority and 18 as
low priority.

Doctors find it difficult to address the sexual problems of
patients because of

Lack of training

Lack of practice

Fear of ?opening the flood gates?

Covert presentation of the problem

Lack of time

Lack of effective treatments

Associated stigma

Embarrassment of doctor, patient or both

Sensitive subject

Difficult subject

Training in psychosexual problems should be
considered by all obstetricians and
gynaecologists. The Institute of Psychosexual Medicine offers a brief, focused course for medical practitioners on psychosomatic therapy for sexual and related difficulties. The initial aim of training is to increase the skills of doctors who encounter women with psychosexual and related problems in their practice. The British Society of Sexual and Relationship Therapists offers training for practitioners of differing backgrounds in psychosexual couple counselling, using a cognitive behavioural approach.

This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

The aim of this web site is to provide a general
guide and it is not intended as a substitute for a consultation
with an appropriate specialist in respect of individual care and
treatment.

David Viniker retired from active clinical practice in 2012. In 1999, he setup this website - www.2womenshealth.com - to provide detailed
information many of his patients requested. The website attracts thousands of visitors every day from around the world.If you would like advice on how to make more from your website, please visit his website Keyword SEO PRO or email him on david@page1-on-google.com.